Provider Demographics
NPI:1477432722
Name:FANKA, CLINTON VENAYUMO
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:VENAYUMO
Last Name:FANKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12811 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-3618
Mailing Address - Country:US
Mailing Address - Phone:227-215-5452
Mailing Address - Fax:
Practice Address - Street 1:2918 MINNESOTA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-1127
Practice Address - Country:US
Practice Address - Phone:227-215-5452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-30
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker